Provider Demographics
NPI:1699816900
Name:ST AUGUSTINE YOUTH SERVICES
Entity Type:Organization
Organization Name:ST AUGUSTINE YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SCHUYLER
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIEFKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-829-1770
Mailing Address - Street 1:201 SIMONE WAY
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-829-1770
Mailing Address - Fax:904-825-0604
Practice Address - Street 1:201 SIMONE WAY
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-829-1770
Practice Address - Fax:904-825-0604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0206-61-16320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029585003Medicaid
FL029585000Medicaid